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Requests for reprints should be addressed to William B. Horton, MD, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216.
Department of Medicine, University of Mississippi Medical Center, JacksonDivision of Endocrinology, University of Mississippi Medical Center, JacksonDepartment of Medicine, G.V. Montgomery VA Medical Center, Jackson, Miss
Uncontrolled hyperglycemia in hospitalized patients with or without a previous diagnosis of diabetes is associated with adverse outcomes and longer lengths of hospital stay. It is estimated that one-third of hospitalized patients will experience significant hyperglycemia, and the cost associated with hospitalization for patients with diabetes accounts for half of all health care expenditures for this disease. Optimizing glycemic control should be a priority for all health care providers in the inpatient setting. Appropriate management strategies should include identification of appropriate glycemic targets, prevention of hypoglycemia, initiation of appropriate basal-plus-bolus insulin regimens, and planning for the transition from inpatient to outpatient therapy before hospital discharge.
Uncontrolled hyperglycemia in hospitalized patients with or without a previous diagnosis of diabetes is associated with adverse outcomes and longer lengths of hospital stay.
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Most hyperglycemic inpatients will require basal plus insulin regimens to mimic normal pancreatic physiology. Insulin-naïve patients can safely initiate treatment by calculating total daily dose.
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Sliding scale insulin alone is insufficient treatment for sustained hyperglycemia.
Uncontrolled hyperglycemia in hospitalized patients with or without a previous diagnosis of diabetes is associated with adverse outcomes and longer lengths of hospital stay.
Centers for Disease Control and Prevention. Crude and age-adjusted percentage of civilian, noninstitutionalized population with diagnosed diabetes, United States, 1980-2011. Available at: http://www.cdc.gov/diabetes/statistics/us/index.htm. Accessed August 17, 2014.
Optimizing glycemic control should be a priority for all health care providers in the inpatient setting.
Consensus Guidelines Exist for the Management of Inpatient Hyperglycemia
The American Diabetes Association and the American Association of Clinical Endocrinologists released a consensus statement on inpatient glycemic control in 2009.
These guidelines note that insulin therapy is the preferred method for achieving inpatient glycemic control. In the intensive care unit, intravenous (IV) infusion is the preferred route of insulin administration. Outside of critical care units, scheduled subcutaneous administration of insulin consisting of basal, nutritional, and supplemental (correction) components is preferred.
In critically ill patients on IV insulin therapy, the blood glucose (BG) level should be maintained between 140 and 180 mg/dL. Targets <110 mg/dL are not recommended for this patient population. For noncritically ill patients treated with subcutaneous insulin, premeal glucose targets should generally be <140 mg/dL in conjunction with random glucose targets <180 mg/dL, as long as these targets can be safely achieved. Higher glucose ranges may be acceptable in terminally ill patients or patients with severe comorbidities. Consideration should be given to reassessing the insulin regimen if BG levels are consistently <100 mg/dL, for avoidance of hypoglycemia.
Inpatient Hyperglycemia Is Best Managed with Insulin
Typically, oral agents have a limited role in the inpatient setting and should be discontinued during acute illness unless it is a very brief hospitalization.
Thiazolidinediones cause fluid retention (especially in combination with insulin) and parenteral glucagon-like peptide-1, and amylin agonists can cause nausea and should be withheld in acutely ill patients.
Insulin works reliably and can be quickly titrated based on changes in diet or glucose levels, making it ideal in the inpatient setting. The Table and the Figure detail the onset and duration of action characteristics by insulin type.
TableDuration and Onset of Action Characteristics by Insulin Type
Hypoglycemia (both spontaneous and iatrogenic) has been associated with higher risk of complications among hospitalized patients, including longer and more expensive hospital stays and increased mortality rates.
For avoidance of hypoglycemia, consideration should be given to reassessing the insulin regimen if BGs <100 mg/dL are consistently noted. Modification of the regimen is necessary when BG values are <70 mg/dL, unless the event is easily explained by other factors such as a missed meal.
POC testing should be performed every 4-6 hours in patients who are not allowed anything by mouth or who are receiving continuous enteral or parenteral nutrition.
Treatment of Inpatient Hyperglycemia Is Cost-effective
In the Portland Diabetic Project, institution of continuous IV insulin therapy to achieve predetermined target BG values in diabetic patients undergoing open-heart surgical procedures reduced the incidence of deep sternal wound infections by 66%, resulting in a total net savings to the hospital of $4638 per patient.
An outpatient follow-up visit with the primary care provider, endocrinologist, or diabetes educator within 1 month after discharge from the hospital is advised for all patients experiencing hyperglycemia while hospitalized.
Clinicians Should Be Aware of Management for Special Clinical Situations
Patients who utilize continuous insulin infusion (pump) therapy in the outpatient setting can be considered for diabetes self-management while hospitalized, provided they have the mental and physical capacity to do so.
Once-daily glargine insulin, premixed human 70/30 insulin given every 8 hours, or a combination of Neutral Protamine Hagedorn insulin given every 12 hours and regular insulin given every 6 hours have all been recommended.
Patients receiving glucocorticoids should be treated with scheduled basal/bolus regimens and will likely require an increase in bolus doses while on glucocorticoid therapy.
Sliding-scale Insulin Alone Is Insufficient Treatment for Sustained Hyperglycemia
Scheduled basal/bolus insulin regimens mimic normal pancreas hormonal physiology and are designed to prevent hyperglycemia, whereas sliding scale insulin (SSI) alone attempts to lower hyperglycemia only after it has occurred.
A study comparing scheduled basal/bolus insulin to SSI alone showed a significantly higher percentage of patients achieving goal glucose levels in the basal/bolus group than in the SSI group (66% vs 38%) without an increase in hypoglycemia.
Effects of a subcutaneous insulin protocol, clinical education, and computerized order set on the quality of inpatient management of hyperglycemia: results of a clinical trial.
Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an insulin management algorithm.
The lower starting dose is recommended for leaner patients and those with renal insufficiency, while the higher starting dose is recommended for obese patients and those on glucocorticoids.
Fifty percent of the calculated total daily dose should be given as a basal component, and the remaining 50% should be split into thirds and given preprandially as the bolus component.
Effects of a subcutaneous insulin protocol, clinical education, and computerized order set on the quality of inpatient management of hyperglycemia: results of a clinical trial.
Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an insulin management algorithm.
Centers for Disease Control and Prevention. Crude and age-adjusted percentage of civilian, noninstitutionalized population with diagnosed diabetes, United States, 1980-2011. Available at: http://www.cdc.gov/diabetes/statistics/us/index.htm. Accessed August 17, 2014.
Effects of a subcutaneous insulin protocol, clinical education, and computerized order set on the quality of inpatient management of hyperglycemia: results of a clinical trial.
Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an insulin management algorithm.
I read with interest “Top Ten Facts to Know About Inpatient Glycemic Control.”1 The authors state that glycemic control should be a priority in the inpatient setting. Notably excluded is the fact that there remains little evidence that tight glycemic control leads to improved clinical outcomes. As the authors note, observational studies have demonstrated a strong association between uncontrolled hyperglycemia (with or without diabetes) and adverse outcome, including mortality.2 This association may be that sicker patients have higher stress levels, and thus manifest worse hyperglycemia.
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